Podcast Summary: Derms on Drugs — “Lasers, Scabies & Dupixent Dilemmas”

Date: February 27, 2026
Hosts: Dr. Matt Zirwas, Dr. Laura Ferris, Dr. Tim Patton
Theme: Exploring hot topics in dermatology with rigorous review and a dose of humor

Episode Overview

In this “six pack episode,” Drs. Zirwas, Ferris, and Patton each bring two noteworthy articles or studies to discuss, covering everything from emerging laser treatments for acne, to dupilumab controversies, scabies dilemmas, pemphigus management, and new safety insights for common derm meds. True to form, the hosts interweave evidence-based discussion with banter, practical pearls, and a hearty dose of sarcasm.

1. Long-term Outcomes with 1726 nm Aviclear Laser for Acne

Lead presenter: Dr. Laura Ferris
Timestamp: 00:57–14:41

Key Points

• Study: Prospective, multicenter, open-label trial of Aviclear (1726 nm laser) for moderate-severe facial acne, tracking outcomes over 1 year.
• Design: Three laser sessions, spaced 2–5 weeks apart. No other acne meds allowed for a year. Blinded photographic assessment.
• Participants: Mostly Fitzpatrick types III-IV. Mean baseline inflammatory lesion count: 61.
• Results:
  • 12 weeks: 49.4% reduction in inflammatory lesion count.
  • 52 weeks: 70% reduction; 91.5% “responders” (>50% reduction).
  • IGA (Investigator's Global Assessment): “Clear or almost clear” at 12 weeks in a third of patients; at 52 weeks in two thirds.
  • Non-inflammatory lesions reduced as well (up to 57% at 52 weeks).
  • QoL: Only 8% highly embarrassed by acne at week 52 vs 56% at baseline.
  • Side effects: Erythema, edema common; mild dryness, initial “purging” reported; no pigmentary changes or blistering.
• No Control Arm: Open-label, no comparator group.

Pearls & Takeaways

• "Would I pay $3,000 out of pocket for this for my own kid? No, I'd use Accutane. But this may have a niche for those avoiding systemic meds." – Ferris (10:08)
• Comparison to topical Cabtreo and Winlevi: Aviclear less effective at 12 weeks but outperforms at long-term; offers a "three sessions and done" regimen.
• Off-label hopes: Interest raised in using Aviclear for sebaceous hyperplasia, oily skin, and possibly hidradenitis suppurativa (HS) (12:06–12:58).

Notable Banter

• "It's where cutting-edge derm meets hit-or-miss comedy… here's your opportunity to learn from people who don't know anything more about lasers than what's in the paper." – Ferris, (01:25)
• "You're boiling your skin—yes, but it's just a little more heating up with the sebum than the general water." – Zirwas (13:54)

2. Maintenance Mycophenolate Post-Rituximab for Pemphigus: No Benefit

Lead presenter: Dr. Tim Patton
Timestamp: 14:45–21:25

Key Points

• Study: Retrospective, 33 patients post-rituximab + mycophenolate + low-dose prednisolone vs 17 on prednisolone alone.
• Finding: No improvement in remission rates or duration; slightly more complete remissions in prednisone-only group (not significant).
• Unique Side Finding: Pred + MMF group had lower CD8+ T-cell counts, suggesting possible increased infection risk.
• Practice Impact: Authors discourage MMF as standard maintenance post-rituximab; Dr. Patton does not routinely use maintenance therapy.

Notable Moment

• "They did a study...demonstrated their standard of care...may not be a good idea." – Patton (17:43)
• "No, I do not [do maintenance], if you don't need it... It's not like maintenance ruxolitinib for atopic derm to keep it under control." – Patton (20:05)

3. Dupilumab and T-Cell Lymphoma Risk: New, Reassuring Data

Lead presenter: Dr. Matt Zirwas
Timestamp: 21:31–26:59

Key Points

• Big Question: Does dupilumab elevate lymphoma or cutaneous T-cell lymphoma (CTCL) risk in atopic dermatitis (AD) patients?
• Study: Large, retrospective trinetX database cohort.
• Findings:
  • AD itself confers a ~10x increased risk of subsequent CTCL diagnosis vs general population (about 1 in 600 patients) (23:01).
  • No additional CTCL risk with dupilumab over other systemic treatments.
  • Dupilumab associated with lower risk of non-Hodgkin’s lymphoma (HR 0.44) and dramatically reduced risk of Sézary syndrome (HR 0.08).
  • "Dupy just might reveal CTCL, but not promote progression." – Zirwas (24:02)
• Prurigo nodularis and CTCL: AI data (31:31) suggested high CTCL risk in prurigo nodularis, but the hosts remain skeptical.

Banter

• "Patton's doing vibe dermatology" – Zirwas (25:52)
• "It's vibe data. Fanatic vibe data." – Zirwas (26:59)

4. Dupilumab and Scabies: A Real (and Worse) Risk

Presenter: Dr. Matt Zirwas
Timestamp: 26:59–31:31

Key Points

• Claim revised: Dr. Zirwas admits prior assertions (“no evidence dupilumab increases parasitic/helminth infections”) were incorrect (26:59).
• Emerging evidence: Dupilumab can worsen or mask scabies, sometimes leading to crusted (“Norwegian”) scabies even in immunocompetent patients due to quashed TH2 immunity and suppression of itch (27:37–29:17).
• Clinical Pearl: If a patient’s “atopic dermatitis” flares or fails to improve or looks weirder after starting dupilumab, suspect scabies or demodex infestation (30:02).
• New diagnostic tip: Woods lamp can make scabies mites fluoresce for easier diagnosis (31:01).
• "If the first drug doesn't work great, think about patch testing, biopsying." – Zirwas (30:02)

5. Spironolactone in Women ≥45: Is Potassium Monitoring Necessary?

Lead presenter: Dr. Laura Ferris
Timestamp: 32:34–41:18

Key Points

• Retrospective review: 398 women over 45 prescribed spironolactone for acne, hair loss, hirsutism, or HS.
• Findings:
  • Hyperkalemia (K+ ≥5) occurred in 10% overall, mostly mild/asymptomatic, average K+ 5.3.
  • Only 1 severe case (K+ >6), most were incidentally detected and managed conservatively.
  • Occurrence mostly after 20 months on drug—not during the “window” often recommended for lab checks.
  • Higher risk with age (>65) and comorbidities (HTN, CKD, diabetes), not with spironolactone dose.
  • Potassium rarely checked per label recommendations (only ~19% within 1 week of starting).
• Clinical Application:
  • For healthy 45–65-year-olds, consider baseline and one follow-up check.
  • More intensive monitoring for older women and/or those with comorbidities.
• Important Drug Interaction: Bactrim + spironolactone can cause severe hyperkalemia (34:26).

Notable Quote

• "62% of cases—nothing changed [despite hyperkalemia]." – Ferris (38:53)

6. HS Stage 1 Progression: Predictors from a Spanish Cohort

Lead presenter: Dr. Tim Patton
Timestamp: 41:48–47:49

Key Points

• Study: 133 Hurley stage 1 HS patients followed (clinical + ultrasound); 37.7% progressed to stage 2/3 in ~2 years.
• Risk factors for progression: Number of cigarettes/day, initial stage 1C, higher abscess count (not nodules), fewer punch drainages.
• Drainage Protective: More punch drainage procedures were associated with lower progression risk—potentially modifiable factor.
• BMI: Not linked to disease progression in this study.
• Antibiotic/biologic associations: Lacking or insufficient data for impact on progression.
• Counseling: Rather than rigid demands, encourage “smoking fewer cigarettes” for better effect with patients.

Quotes

• "We're not saying you can't smoke any cigarettes. Just smoke fewer." – Patton (45:21)
• "Draining abscesses may help prevent progression..." – Patton (46:51)

7. Miscellaneous Clinical Pearls and New Findings

a. Zinc for Skin Toxicity in Oncology

Patton, 47:53–48:42:

• Zinc deficiency linked to rash/dysgeusia from enfortumab vedotin (oncodrug)—supplementing zinc may help resolve rash.

b. Jack Inhibitors and Memory Impairment

Zirwas, 49:16–52:14:

• WHO Vigibase data: Small signal for memory/cognitive impairment (odds ratio ~3 for tofacitinib), sometimes reversible, likely cumulative effect. More data needed, but now something to monitor.

c. Shared Decision Aids are Too Complicated

Zirwas, 52:14–55:58:

• Doctors persistently overcomplicate patient choice tools for atopic dermatitis therapies; staged, binary (“A or B?”) choices are more effective.

• "Best shared decision making—give patients one decision at a time, like A vs B, just like at a restaurant. Then keep narrowing choices." – Zirwas (54:15)

8. Practical Counseling & Real-world Practice

Timestamp: 55:58–58:52

• When asked “What would you do, doc?" all three hosts say they share their own choices but frame them as personal preferences, like recommending a dish at a new restaurant (55:58–56:32).
• For moderate/severe atopic derm, all lean toward recommending dupilumab as “first-line” due to superior safety, experience, and not requiring lab monitoring, unless needle phobia is significant.
• Interesting note: Several patients find dupilumab injections particularly painful, sometimes more than other injectables (58:25–58:52).

Notable Quotes & Moments

• On Aviclear:
  "You're boiling your skin—yes, but it's just a little more heating up with the sebum..." – Zirwas (13:54)
• On maintenance therapy in pemphigus:
  "They did a study...May not be a good idea." – Patton (17:43)
• On recognizing persistent “AD” with failed dupilumab:
  "Don't just try another drug—a non-responder should trigger deeper investigation (patch test, biopsy, r/o parasites)." – Zirwas (30:02)
• On patient counseling:
  "It’s like being at a restaurant: I may recommend the salmon, but if you hate fish, it’s not right for you." – Zirwas (55:43)
• Best shared decision-making advice:
  "Always give an A vs B—it’s just simpler for patients." – Zirwas (54:15)

Quick Timestamps for Key Segments

• Aviclear laser for acne: 00:57–14:41
• Pemphigus and mycophenolate: 14:45–21:25
• Dupilumab & lymphoma risk: 21:31–26:59
• Dupilumab & scabies: 26:59–31:31
• Spironolactone & potassium in women over 45: 32:34–41:18
• HS (hidradenitis) stage progression factors: 41:48–47:49
• Zinc & drug rashes: 47:53–48:42
• JAK inhibitors & memory: 49:16–52:14
• Decision aids & counseling: 52:14–58:52

Final Thoughts

This episode delivers a comprehensive, practical, and laugh-filled quick-fire review of emerging dermatology evidence, with takeaways directly applicable to clinical decision-making on lasers, immunotherapies, scabies, safety monitoring, and beyond. As ever, the hosts' blend of dry wit, sharp clinical reasoning, and willingness to challenge their own assumptions makes this essential listening for dermatology professionals.